BILL NUMBER: SB 745	CHAPTERED  09/28/00

	CHAPTER   811
	FILED WITH SECRETARY OF STATE   SEPTEMBER 28, 2000
	APPROVED BY GOVERNOR   SEPTEMBER 28, 2000
	PASSED THE SENATE   AUGUST 31, 2000
	PASSED THE ASSEMBLY   AUGUST 30, 2000
	AMENDED IN ASSEMBLY   AUGUST 29, 2000
	AMENDED IN ASSEMBLY   AUGUST 7, 2000
	AMENDED IN ASSEMBLY   JUNE 22, 2000
	AMENDED IN ASSEMBLY   MARCH 15, 2000
	AMENDED IN SENATE   MAY 28, 1999
	AMENDED IN SENATE   MAY 18, 1999
	AMENDED IN SENATE   MAY 10, 1999

INTRODUCED BY   Senator Escutia

                        FEBRUARY 24, 1999

   An act to add Sections 5777.5, 5777.6, and 14456.5 to the Welfare
and Institutions Code, relating to mental health.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 745, Escutia.  Mental health:  contracts:  disputes.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Services, pursuant to
which medical benefits are provided to public assistance recipients
and certain other low-income persons.  Existing law further provides
that the State Department of Mental Health shall implement managed
mental health care for Medi-Cal beneficiaries through fee-for-service
or capitated rate contracts with mental health plans.
   This bill would require the State Department of Mental Health to
require any mental health plan that provides Medi-Cal services to
enter into a memorandum of understanding containing specified
requirements with any Medi-Cal managed care plan that provides
Medi-Cal health services to some of the same Medi-Cal recipients
served by the mental health plan.
   The bill would require the establishment of a procedure to ensure
access to outpatient mental health services, as required by the Early
Periodic Screening and Diagnostic Treatment program standards, for
any child in foster care who has been placed outside his or her
county of adjudication.  The imposition of these requirements on
counties of adjudication would create a state-mandated local program.

   This bill would further require the State Department of Health
Services to ensure that coverage is provided for necessary
prescription medications and related medically necessary medical
services that are prescribed by a local mental health plan provider,
and that are within the Medi-Cal scope of benefits, but are excluded
from coverage under the above-described requirements applicable to
the State Department of Mental Health.
  The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state.  Statutory provisions establish procedures for making that
reimbursement, including the creation of a State Mandates Claims Fund
to pay the costs of mandates that do not exceed $1,000,000 statewide
and other procedures for claims whose statewide costs exceed
$1,000,000.
   This bill would provide that, if the Commission on State Mandates
determines that the bill contains costs mandated by the state,
reimbursement for those costs shall be made pursuant to these
statutory provisions.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  The Legislature finds and declares all of the
following:
   (a) Persons who receive Medi-Cal mental health services through
mental health plans pursuant to Part 2.5 (commencing with Section
5775) of Division 5 and Article 5 (commencing with Section 14680) of
Chapter 8.8 of Part 3 of Division 9 of the Welfare and Institutions
Code, require timely access to prescription drugs prescribed by the
Medi-Cal mental health plan providers because these prescription
drugs may be crucial to maintaining stability and furthering
treatment goals.
   (b) Disputes about responsibility for authorizing or providing
specific prescription drugs prescribed by Medi-Cal mental health plan
providers have the effect of disrupting the timely access to
prescription drugs needed by persons receiving services through
Medi-Cal mental health plans.
   (c) Medi-Cal recipients have the right to timely access to
prescription  drugs regardless of the entity responsible to provide
or authorize coverage.
   (d) Foster children who are placed outside their county of
residence and who need specialty mental health services provided by
county mental health plans encounter delays and difficulties in
accessing these specialty mental health services.
   (e) Under the federal Medicaid Act, including the Balanced Budget
Act of 1997, the state has special responsibilities to children in
foster care including those who are placed outside their county of
residence.  The state must ensure that foster children placed outside
their county of residence receive timely and appropriate access to
necessary mental health services, including mental health services
pursuant to the federal Early and Periodic Screening, Diagnosis and
Treatment Program (42 U.S.C. Sec. 1396d(a)(4)(B).
  SEC. 2.  It is the intent of the Legislature that access to
prescription medications and other services for Medi-Cal recipients
who receive mental health services through county mental health plans
and who are also members of Medi-Cal managed care plans or other
health care plans shall be no less than the timely access enjoyed by
Medi-Cal recipients who are not members of Medi-Cal managed care
plans or who do not have other health care coverage.
  SEC. 3.  Section 5777.5 is added to the Welfare and Institutions
Code, to read:
   5777.5.  (a) (1) The department shall require any mental health
plan that provides Medi-Cal services to enter into a memorandum of
understanding with any Medi-Cal managed care plan that provides
Medi-Cal health services to some of the same Medi-Cal recipients
served by the mental health plan.  The memorandum of understanding
shall comply with applicable regulations.
   (2) For purposes of this section, a "Medi-Cal managed care plan"
means any prepaid health plan or Medi-Cal managed care plan
contracting with the  State Department of Health Services to provide
services to enrolled Medi-Cal beneficiaries under Chapter 7
(commencing with Section 14000) or Chapter 8 (commencing with Section
14200) of Part 3 of Division 9, or Part 4 (commencing with Section
101525) of Division 101 of the Health and Safety Code.
   (b) The department shall require the memorandum of understanding
to include all of the following:
   (1) A process or entity to be designated by the local mental
health plan to receive notice of actions, denials, or deferrals from
the Medi-Cal managed care plan, and to provide any additional
information requested in the deferral notice as necessary for a
medical necessity determination.
   (2) A requirement that the local mental health plan respond by the
close of the business day following the day the deferral notice is
received.
   (c) The department may sanction a mental health plan pursuant to
paragraph (1) of subdivision (e) of Section 5775 for failure to
comply with this section.
   (d) This section shall apply to any contracts entered into,
amended, modified, extended, or renewed on or after January 1, 2001.

  SEC. 4.  Section 5777.6 is added to the Welfare and Institutions
Code, to read:
   5777.6.  (a) Each local mental health plan shall establish a
procedure to ensure access to outpatient mental health services, as
required by the Early Periodic Screening and Diagnostic Treatment
program standards, for any child in foster care who has been placed
outside his or her county of adjudication.
   (b) The procedure required by subdivision (a) may be established
through one or more of the following:
   (1) The establishment of, and federal approval, if required, of, a
  statewide system or procedure.
   (2) An arrangement between local mental health plans for
reimbursement for services provided by a mental health plan other
than the mental health plan in the county of adjudication and
designation of an entity to provide additional information needed for
approval or reimbursement.  This arrangement shall not require
providers who are already credentialed or certified by the mental
health plan in the beneficiary's county of residence to be
credentialed or certified by, or to contract with, the mental health
plan in the county of adjudication.
   (3) Arrangements between the mental health plan in the county of
adjudication and mental health providers in the beneficiary's county
of residence for authorization of, and reimbursement for, services.
This arrangement shall not require providers credentialed or
certified by, and in good standing with, the mental health plan in
the beneficiary's county of residence to be credentialed or certified
by the mental health plan in the county of adjudication.
   (c) The department shall collect and keep statistics that will
enable the department to compare access to outpatient specialty
mental health services by foster children placed in their county of
adjudication with access to outpatient specialty mental health
services by foster children placed outside of their county of
adjudication.
  SEC. 5.  Section 14456.5 is added to the Welfare and Institutions
Code, to read:
   14456.5.  (a) For purposes of this section, Medi-Cal managed care
plan means any prepaid health plan or Medi-Cal managed care plan
contracting with the department to provide services to enrolled
Medi-Cal beneficiaries under Chapter 7 (commencing with Section
14000) or this chapter, or Part 4 (commencing with Section 101525) of
Division 101 of the Health and Safety Code.
   (b) The department shall ensure that coverage is provided for
medically necessary prescription medications and related medically
necessary medical services that are prescribed by a local mental
health plan provider, and are within the Medi-Cal scope of benefits,
but are excluded from coverage under Part 2.5 (commencing with
Section 5775) of Division 5, by doing, at least, all of the
following:
   (1) Requiring Medi-Cal managed care plans to comply with the
following standards:
   (A) The decision regarding responsibility and coverage for a
prescription drug shall be made by the Medi-Cal managed care plan
within 24 hours, or one business day, from the date the request for a
decision is received by telephone or other telecommunication device.

   (B) The decision regarding responsibility and coverage for
services, such as laboratory tests, that are medically necessary
because of medications prescribed by a mental health provider, shall
be made by the Medi-Cal managed care plan within seven days following
the date the request for a decision is received by telephone or
other telecommunication device.
   (C) If the decision of the Medi-Cal managed care plan on the
request is a deferral because of a determination that the Medi-Cal
managed care plan needs more information, the Medi-Cal managed care
plan shall transmit notice of the deferral, by facsimile or by other
telecommunication system, to the pharmacist or other service
provider, to the prescribing mental health provider, and to a
designated mental health plan representative.  The notice shall set
out with specificity what additional information is needed to make a
medical necessity determination.
   (D) Any denial of authorization or payment for a prescription
medication or for any services such as laboratory tests that may be
medically necessary because of medications ordered by a mental health
plan provider shall set forth the reasons for the denial with
specificity.  The denial notice shall be transmitted by facsimile or
other telecommunication system to the pharmacist or other service
provider, to the prescribing mental health provider, to a designated
mental health plan representative, and by mail to the Medi-Cal
beneficiary.
   (E) For purposes of subsequent requests for a medication, the
local mental health plan provider prescribing the prescription
medication shall be treated as a plan provider under subdivision (a)
of Section 1367.22 of the Health and Safety Code.
   (F) If the decision cannot be made within five working days
because of a request for additional information, any Medi-Cal managed
care plan licensed pursuant to Division 2 (commencing with Section
1340) of the Health and Safety Code shall inform the enrollee as
required by paragraph (5) of subdivision (h) of Section 1367.01 of
the Health and Safety Code.  In regard to any Medi-Cal managed care
plan contract as described pursuant to subdivision (a) that is
issued, amended, or renewed on or after January 1, 2001, with a plan
not licensed pursuant to Division 2 (commencing with Section 1340) of
the Health and Safety Code, if the decision cannot be made within
five working days because of a request for additional information as
specified in subparagraph (C), the plan shall notify the enrollee, in
writing, that the plan cannot make a decision to approve, modify, or
deny the request for authorization.  All managed care plans shall,
upon receipt of all information reasonably necessary for making the
decision and that was requested by the plan, approve, modify, or deny
the request for authorization within the timeframes specified in
subparagraph (A) or (B), whichever applies.
   (2) In consultation with the Medi-Cal managed care plans, the
State Department of Mental Health, and local mental health plans
establishing a process to recognize credentialing of local mental
health plan providers, for the purpose of expediting approval of
medications prescribed by a local mental health plan provider who is
not contracting with the Medi-Cal managed care plan.  In implementing
this requirement, the Medi-Cal managed care plan shall not be
required to violate licensure, accreditation, or certification
requirements of other entities.
   (3) Requiring any Medi-Cal managed care plan to enter into a
memorandum of understanding with the local mental health plan.  The
memorandum of understanding shall comply with applicable regulations.

   (c) The department may sanction a Medi-Cal managed care plan for
violations of this section pursuant to Section 14088.23 or 14304.
   (d) Every Medi-Cal managed care plan that provides prescription
drug benefits and that maintains one or more drug formularies shall
provide to members of the public, upon request, a copy of the most
current list of prescription drugs on the formulary of the Medi-Cal
managed care plan, by therapeutic category, with an indication of
whether any drugs on the list are preferred over other listed drugs.
If the Medi-Cal managed care plan maintains more than one formulary,
the plan shall notify the requester that a choice of formulary lists
is available.
   (e) This section shall apply to any contracts entered into,
amended, modified, or extended on or after January 1, 2001.
  SEC. 6.  Notwithstanding Section 17610 of the Government Code, if
the Commission on State Mandates determines that this act contains
costs mandated by the state, reimbursement to local agencies and
school districts for those costs shall be made pursuant to Part 7
(commencing with Section 17500) of Division 4 of Title 2 of the
Government Code.  If the statewide cost of the claim for
reimbursement does not exceed one million dollars ($1,000,000),
reimbursement shall be made from the State Mandates Claims Fund.
